Clinical Review Nurse - Concurrent Review

Centene Management Company LLC; Washington; Hybrid; USD 37,000 - 67,000; Full time

Benefits offered by this job

Remote work

Health insurance

401K plan

Tuition reimbursement

Paid time off

Flexible schedules

Job summary

Centene Management Company LLC is seeking a remote Nurse Reviewer to perform concurrent reviews, determine the member’s health status, and oversee appropriate levels of care across Medicaid and Market Place plans. You will collaborate with Medical Affairs and discharge planning teams while educating providers on utilization processes.

The ideal candidate holds a nursing degree with 5+ years of nursing experience, including acute care, and preferably compact licensure.

Qualifications

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing.
• 2–4 years of related experience in nursing.
• 2+ years of acute care experience required.
• Knowledge of Medicare and Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.

Responsibilities

• Perform concurrent reviews to assess overall member health and appropriate level of care.
• Review acuity, resource use, length of stay, and discharge planning.
• Collaborate with Medical Affairs/Directors to discuss member care.
• Educate providers on utilization processes to ensure quality care.
• Document findings and maintain discharge plans in health management systems.
• Assist with coordinating transfer or discharge across facilities.

Skills

Clinical assessment

Discharge planning

Utilization management

Education

Bachelor’s degree in Nursing

Job description

Position Purpose

Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.

Key Details

This position is fully remote/work from home, and will support Medicaid and Market Place/Ambetter members for Post Acute Care. Looking for applicants who reside in either Central Time Zone, Mountain Time Zone or Pacific Time Zone and ideally hold a compact nursing licensure. Experience should include LTACH, IPR or SNF experience with a minimum of 5 years nursing experience. The work schedule will be Monday-Friday 8am - 5pm based on the time zone in which you reside, and will have rotational Saturdays and holidays. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care. Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member. Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered. Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines. Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings. Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members. Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines. Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities. Collaborates with care management on referral of members as appropriate. Performs other duties as assigned. Complies with all policies and standards.

Education/Experience

Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred.

License/Certification

LPN - Licensed Practical Nurse - State Licensure required. RN - Registered Nurse - State Licensure and/or Compact State Licensure for State of Nevada required.

Pay Range

$27.02 - $48.55 per hour

Company Culture

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.

Benefits

• Competitive pay
• Health insurance
• 401K and stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• A flexible approach to work with remote, hybrid, field or office work schedules

Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

Diversity & Inclusion / EEO

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act